December 4, 2012 Michael Toboni and Brian Chou with Dr. Brian Prestwich

1. December 4, 2012 Michael Toboni and Brian Chou with Dr. Brian Prestwich Executive Board Members: Emily Levy, Joseph Li, NataneRunningfox, SadiaQuidwai, Megan Chen, Yvonne Hoang, Mena Alrais

2. 200+ Student Volunteers 25+ Preceptors 4 Health Professions Medicine Occupational Therapy Pharmacy Physician Assistant 2 Clinic Sites LAC + USC Urgent Care Eisner + USC Med Center Who We Are

3. Care Team 1 Clinic Coordinator 2 Medical Students 2 Pharmacy Students 1 OT Student 1 PA Student Supervising Faculty Patient Services Preventative Screening Lifestyle Modification Medical Assessment Medication Therapy Mgmt Medical Home Linkage Cycle Time 70 Min per Patient Who We Are • We are students working together in interprofessionalcare teams to help deliver comprehensive care to the chronically ill and underserved population of Los Angeles.

4. Primary Care Project at USC+ Eisner Family Medicine Center Urgent Care Project at LAC+USC Urgent Care Center What We Do

5. The Clinic Protocol

6. Pre-Clinical Medical Students Vital Signs Preventative Services Patient Education Medical History Physical Exam Clinical Medical Students Assessment & Planning Teaching and Supervision Charting Medicine

7. Medical History Physical Exam Treatment Planning Patient Education Verbal Case Reports Charting Physician Assistant

8. Medication Therapy Management Medication History Medication Reconciliation Drug Assessment Appropriateness Effectiveness Safety Design new medication regimen Patient Education Pharmacy

9. Increase patient engagement in chronic condition self-management and preventative health behaviors. Collaborate with team to create an individualized wellness action plan. The Lifestyle Redesign® Approach. The process of acquiring health-promoting habits and routines in daily life. Patient education Daily activity analysis Goal setting Occupational Therapy

10. Clinical Training Charting Case Presentation Procedural Skills Interviewing Skills Cultural Sensitivity Policy Training Medical Home Model Challenges to Access Collaborative Solutions All Participants • Students are • exposed to other disciplines, • work as a clinicalteam, • and adopt an analytical, case-based approach to patient care • …as early as their first year of school.

11. Inter-Professional Health Symposium Inter-Professional Health Fairs Research Other Projects

12. Michael Toboni, Co-President Brian Chou, Co-President Brian Prestwich, Medical Director Questions? uscstudentrunclinic@gmail.com

13. The Phillips Neighborhood Clinic Brian Sick, MD – Medical Director Anna Berglund, MS2 – Board Co-Chair Autumn Chmielewski, MHA2 – Board Co-Chair

14. Where are we? - The Phillips Neighborhood South Minneapolis Urban Diverse - 31.3% foreign born residents Impoverished - 34.4% below poverty level Accessible - metro transit buses -lightrail system Active Neighborhood - many non-profits - large employers

15. Where are we? – The Phillips Neighborhood Clinic (PNC)PNC is located in the heart of the Phillips Neighborhood and operates from the basement of Oliver Presbyterian Church.Picture is of: 2647 Bloomington Avenue South Minneapolis, MN 55407 PNC is located in the heart of the Phillips Neighborhood and operates from the basement of Oliver Presbyterian Church. 2647 Bloomington Avenue South Minneapolis, MN 55407

16. Who are we? – Our Two-part Mission Patient Centered To provide accessible, culturally appropriate, interdisciplinary health care services and education in order to reduce the burdens of poor medical access and raise the quality of life for our patients.

17. Who are we? Our Two-part Mission Student Centered To provide health professional students with the skills they need to effectively and compassionately serve people who are underinsured and/or unstably housed.

18. Who do we serve? – Our Patients • Approximately 1,200 patient visits annually • All services are free and provided to anyone in need • Patients are served on a first-come-first-served basis two nights per week

19. Who do we serve? – Our Patients

20. What services do we offer?

21. How do we do it? – Our Structure

22. How do we do it? – Our Volunteers 328 Student Volunteers 100 Medical 72 Pharmacy 55 Public Health* 40 Nursing 38 Physical Therapy 15 Social Work 8 Undergraduate * Includes Nutrition & Master of Healthcare Administration

23. How do we do it? – Volunteer Commitment 328 Student Volunteers • Sign contract for 2 years of 2 semesters per year (summer optional) • Hours per semester = 35 • 3-4 clinic shifts x 5 hours each = 20 hours • 3 outreach activities x 3 hours each = 9 hours • 4 meetings x 1 hour each = 4 hours • 1 cultural awareness event = 2 hours Value of time student volunteers commit to the clinic per year = $496,395

24. How do we do it? – Our Preceptors 86 Volunteer Preceptors Medical Nursing Nutrition Physical Therapy Pharmacy Residents Med/Ped’s Family Medicine

25. How do we do it? – Our Expenses • Total annual operating expenses are approximately $40,000 • Includes the cost to provide free labs &medications for 1,200+ patient visits per year, building rent, utilities, training materials, & fundraising costs • The average cost to serve each patient = $31.00

26. How do we do it? – Our Income & SupportUniversity of Minnesota Physicians: UMP helps manage clinic operations by working with PNC leadership to determine medical supplies, computers, EMR, and sign facility leaseUniversity of Minnesota: Medical school administration develops an annual budget with PNC officials with the understanding that PNC raises funds to cover as much of the budget as possible Minnesota Medical Foundation: UMN approved foundation for Health Sciences. PNC can receive donations and gifts through the foundation, which is a 501 (c) 3 organizationPhillips Neighborhood Clinic: PNC is classified as a campus life program. All financial transactions are processed through the University. • Income comes from a variety of sources including fundraising, donations, & grants • Significant in-kind support is provided by supporting organizations Phillips Neighborhood Clinic PNC is classified as a campus life program. All financial transactions are processed through the University.

27. What else makes us unique? – Community Outreach • Student volunteers commit to 6 community outreach activities per year • Activities include tutoring, diabetes education, blood pressure & blood sugar checks, health fairs, legislative advocacy, meal service, etc… • We can only see so many patients in clinic, but we can help many more outside of the clinic

28. What else makes us unique? – Interdisciplinary Approach • 6 different schools are represented at PNC (medical, nursing, pharmacy, physical therapy, public health, & social work) • Clinic “huddles” draw on insights and expertise from each profession to diagnose patients and create care plans • Students learn firsthand that collaborative care is best for the patients

29. Neighborhood Phillips Neighborhood Clinic: Providing culturally competent care and cultivating caring future healthcare leaders

30. Crimson Care Collaboratives (CCC) Harvard Medical School Student-Faculty Collaborative Practices Presented by Rebecca Berman MD, JuwaratKadiri & Jessica O’Brien

31. 5 Evening Clinics, planning began fall of 2009 CCC- MGH Internal Medicine Associates (CCC-IMA), October 2010 CCC- MGH Chelsea, October 2011 CCC- Beth Israel Deaconess (CCC-BIDMC), January 2012 CCC- MGH Revere, October 2012 CCC- Cambridge,  November 2011 Student-Faculty Collaborative practices HMS MD, DMD students MGH Institute for Health Professions – NP students clinical and nonclinical roles since summer 2011 Harvard Undergraduates nonclinical roles since summer 2010 HMS faculty CCC – Overview

32. Needs Assessment Post Massachusetts Health-Reform • Long wait times for new PCP appointments • Only 44% of IM practices accepting new patients (down from 66% pre-Health reform) • 45% of adults using the ER for non-emergent reasons unable to get a PCP appointment MMS Physician Workforce Study 2009, 2008 Massachusetts Health Reform Survey (Long and Masi, Health Affairs 28 May 2009)

33. Needs & Ethical Concerns • Need for acute access to primary care services • Need for meaningful student experiences in primary care • Ethical concerns met by: • Faculty partnership, supervision, and mentorship • High quality benchmarks • Student-faculty collaborative practices

34. Overriding Themes • Student-driven initiative w/close faculty support • Student exposure to & participation in primary care in a multidisciplinary approach • Strong social mission by increasing access to care or addressing social needs • Commitment to quality through stringent attending-level supervision • Development of innovative solutions to community or organizational problems

35. CCC – MGH IMA • Primary care and urgent care services, social services, embedded research team • 50% Bridge-to-Care Patients • Do not have PCP, frequent fliers to ER (MGH primary care closed to new patients otherwise) • Patients transitioned to a long-term PCP through social service center • 50% Urgent Care Patients • Urgent care visits from patients who have a PCP at MGH Internal Medicine Associates • Addresses Ethical Concerns • 2012: Inter-professional teams of medical and NP students, interchangeable roles

36. CCC – MGH CHELSEA • Primary care services, social services, mental health services, embedded research team • Patients who have just been released from prison • Highly vulnerable population • Patients frequently seeking care at Chelsea HealthCare Center’s Urgent Care Clinic • Predominantly immigrants/refugees • Lack access to primary care • 2012: Interprofessional teams of medical and NP students, interchangeable roles

37. CCC – BIDMC • Needs assessment revealed BIDMC had access available in their resident clinic, need for chronic disease management • Chronic Disease Co-Management Model • Diabetes, hypertension, COPD • Focus on motivational interviewing, patient education • Titrate meds, check labs as indicated • Embedded research team • Urgent Care • Future direction of more team-based care • Non-physician health professionals – have run into political difficulties getting NP/PA students involved 2/2 multiple different NP programs at BIDMC

38. CCC – MGH Revere (pediatrics) • Needs assessment • Pediatricians have openings • Need for expanded hours and obesity co-management • Difficult for students to get exposure to pediatrics • Pediatric patients • Well child and after hours urgent care • Group visit model being piloted surrounding healthy eating/weight management in obese patients not eligible for other services • Inter-professional team of medical and NP students, interchangeable roles • Community health center • Ethnically diverse, predominantly low SES

39. CCC – Cambridge • Located in YWCA • Women in transitional housing (residents have history of physical, psychosocial or financial trauma) • Initial plan was monthly outreach to bridge patients to a PCP • Many residents have PCPs but don’t go to them due to multiple psycho-social barriers • Students as patient navigators • Health screening, including mental health and social services needs, help make PCP appointments and go with patients

40. Statistics • Each clinic sees between 6-12 patients per night, total monthly capacity ~ 100 patients • Clinic lasts ~3 hours, volunteers must come at least monthly • Board members work ~ 5-10 hours per week on CCC-related planning • 473 student volunteers to date • This semester: 180 HMS/HSDM, 24 NP, 32 Harvard College, 3 post-baccalaureate/graduate students

41. Clinic Sustainability • Average annual cost to operate a clinic = 100K • Funding Sources • Insurance accepted post health reform (wRVUs) • In-kind support from participating practices • Teaching dollars from Harvard Medical School • Grants including MGH Stoeckle Center for Primary Care Innovation, Yawkey II Foundation, HMS Center for Primary Care

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